Net reclassification improvement with serial biomarkers and bed-sided spirometry to early predict the need of organ support during the early post-transplantation in-hospital stay in allogeneic HCT recipients.

To predict the need of intensive care unit admission with organ support during the transplantation hospital stay in 101 consecutives allogeneic hematopoietic cell transplantation (allo-HCT) recipients the added predictive utility of three times per week Copeptin, MR-proADM, MR-proANP, NT-proBNP, IL-6, Procalcitonin, D-dimer and three times per week bed-sided pulmonary function test was determined in comparison with an index model. The index model was calculated by multivariate regression analysis out of the patients' routine laboratory parameters. To calculate the added predictive utility of the investigated markers the Δ-AUC and the continuous net reclassification improvement (cNRI + 2 to - 2), splitted for events and non-events were calculated for each marker in comparison with the index model. According to the Δ-AUC, none of the parameters improved risk prediction. In contrast, the cNRI was significantly improved for events and non-events by Copeptin (event 0.75, p value 0.0013; non-event 0.4, p value 0.000079) and for events by NT-proBNP (0.6, p value 0.018). D-dimer and PCT significantly predicted the non-event. Of the spirometry parameters, the FEF50% improved prediction of event and non-event according to the cNRI model. Our data support the additional serial analysis of Copeptin and NT-proBNP in allo-HCT recipients during the transplantation hospital stay.

Drug-induced progressive multifocal leukoencephalopathy in multiple sclerosis: European regulators' perspective.

Progressive multifocal leukoencephalopathy (PML) has been associated with the use of a number of multiple sclerosis (MS) immunomodulatory therapies and has assumed a critical place in the evaluation of their benefit/risk. In this review, we discuss the European Union regulatory approach to drug-induced PML in MS, highlight a number of key issues related to the current knowledge on PML, and outline possible paths to help progress the risk management of patients with MS at risk of PML.

[Opportunities and challenges of extrapolation for biosimilars]. / Möglichkeiten und Herausforderungen der Extrapolation bei Biosimilars.

Although biosimilars approved in the European Union have proved to be safe and efficacious, their licensing requirements continue to be disputed by medical professionals. In particular, extrapolation to indications of the originator without one's own clinical data of the biosimilar is controversial. Conceptually, the development of biosimilars is derived from that of generics. However, due to their complexity and inherent variability, considerably more data are necessary for biosimilars to demonstrate comparability with the originator (the reference product) than for the usually low-molecular generics. Biosimilars increase competition and help contain healthcare, and they improve access for patients to valuable treatments with biologicals. However, biosimilar development is a laborious and lengthy process and requires major biotechnological know-how. The basis is comprehensive, structural, and functional characterization of the biosimilar and reference product as well as their comparison with suitable and sensitive methods. The clinical development programme is reduced and tailored to address remaining uncertainties and to confirm comparable clinical performance. Extrapolation of data to other indications of the reference product is the greatest cost advantage of biosimilar development, but must always be scientifically justified and, if necessary, substantiated by further data. The scientific principles underlying the comparability exercise for a biosimilar are the same as those applied to a change in the manufacturing process of an already licensed biological. In both cases, different versions of a biological substance are compared and the clinical relevance of observed differences is assessed. Competent authorities do have decades of experience in evaluating changes in the manufacturing process, which they can now apply to biosimilars. For approval of a biosimilar and extrapolation of data, the totality of the evidence from the complete comparability exercise is considered, as has been the case for the first biosimilar infliximab.

Efficacy and patient satisfaction of breast conserving therapy for central breast cancer by the B technique.

PURPOSE: To evaluate the oncologic safety and cosmetic results after breast cancer surgery for central breast cancer by the B technique. METHODS: Seventy women with operable breast cancer located in the central portion of the breast that had received resection surgery with the B technique were recruited. The primary outcome was the oncological safety, quantified as rate of positive resection margins and the cosmetic outcome evaluated by postsurgical self-assessment of the cosmetic outcome via questionnaire. The median follow-up period was 61.4 months (range 7.9-142.6 months). RESULTS: With one exception all patients had T1-2 tumors less than 5 cm in diameter. Most patients had invasive ductal breast cancers (57.1 %), followed by ductal carcinoma-in situ (27.1 %) and invasive lobular breast cancers (8.6 %). The incidence of positive resection margins was 17.1 %. No local tumor recurrence occurred during follow-up; one patient had distant metastases. In total, 80 % of the patients reported that the cosmetic results met or exceeded their expectations. CONCLUSIONS: The B technique is a safe breast conservation surgery for the excision of tumors located in the central portion of the breast and yields a high rate of satisfactory cosmetic results.

Suppression of the nuclear factor Eny2 increases insulin secretion in poorly functioning INS-1E insulinoma cells.

Eny2, the mammalian ortholog of yeast Sus1 and drosophila E(y)2, is a nuclear factor that participates in several steps of gene transcription and in mRNA export. We had previously found that Eny2 expression changes in mouse pancreatic islets during the metabolic adaptation to pregnancy. We therefore hypothesized that the protein contributes to the regulation of islet endocrine cell function and tested this hypothesis in rat INS-1E insulinoma cells. Overexpression of Eny2 had no effect but siRNA-mediated knockdown of Eny2 resulted in markedly increased glucose and exendin-4-induced insulin secretion from otherwise poorly glucose-responsive INS-1E cells. Insulin content, cellular viability, and the expression levels of several key components of glucose sensing remained unchanged; however glucose-dependent cellular metabolism was higher after Eny2 knockdown. Suppression of Eny2 enhanced the intracellular incretin signal downstream of cAMP. The use of specific cAMP analogues and pathway inhibitors primarily implicated the PKA and to a lesser extent the EPAC pathway. In summary, we identified a potential link between the nuclear protein Eny2 and insulin secretion. Suppression of Eny2 resulted in increased glucose and incretin-induced insulin release from a poorly glucose-responsive INS-1E subline. Whether these findings extend to other experimental conditions or to in vivo physiology needs to be determined in further studies.

Características dos componentes não integrantes da carcaça de novilhos superjovens da raça Devon, terminados em diferentes sistemas de alimentação / Characteristics of non-integrant components of carcass of Devon young steers, finished in different feeding systems

O objetivo do estudo foi avaliar as características dos componentes não integrantes da carcaça de novilhos Devon terminados em confinamento (CONF), em pastagem de clima temperado (pastagem de azevém - Lolium multiflorum Lam - PTEM) ou em pastagem de clima tropical (associação de pastagem de milheto - Pennisetum americanum (L.) Leeke - e capim-papuã - Bracharia plantaginea - PTRO). Os novilhos, ao início da terminação, estavam com 320kg e 15 meses de idade. Os animais confinados foram alimentados com relação volumoso:concentrado de 60:40; o volumoso era constituído de silagem de milho, e o concentrado de farelo de trigo, milho e minerais. Os animais foram abatidos com pesos semelhantes de 388,3; 386,7 e 375,8kg no CONF, na PTEM e na PTRO, respectivamente. Os animais da PTRO apresentaram maior (P<0,10) rendimento de carcaça quente (RCQ) relativo a 100kg de peso corporal vazio (RCQPCV) do que os da PTEM, 64,6 versus 62,6 por cento, e os do CONF apresentaram RCQPCV intermediário, 63,7 por cento. Os pesos absolutos do fígado, 5,22; 4,43 e 3,87kg, do conjunto dos órgãos internos, 12,81; 11,37 e 10,83kg, do rúmen-retículo, 7,62; 6,54 e 6,06kg, da gordura do coração, 1,26; 0,65 e 0,30kg, e dos intestinos, 9,97; 7,13 e 7,49kg, foram mais altos (P<0,05) nos animais da PTEM, em relação aos do CONF e da PTRO, respectivamente. A mesma ordem de grandeza ocorreu com os pesos relativos desses órgãos. A PTRO e o CONF originaram animais com maior (P<0,05) peso de conteúdo gastrintestinal em relação à PTEM, respectivamente, 60,27; 55,32 e 41,21kg. O CONF proporcionou animais com pesos absolutos mais elevados (P<0,05) do omaso, 5,17kg, em relação aos da PTEM, 3,70kg, e este peso foi intermediário nos animais da PTRO, 4,77kg. A mesma ordem de grandeza ocorreu com os pesos relativos do omaso, 1,61; 1,12 e 1,54 por cento.

The non-integrant components of carcass of Devon steers were evaluated. Animals were finished in feedlot (CONF), winter pasture (pasture of ryegrass - Lolium multiflorum Lam -PTEM), or tropical pasture (association of millet pasture - Pennisetum americanum (L.) Leeke - and Alexander Grass - Brachiaria plantaginea - PTRO). At the beginning of finishing, the average weight of steers was 320kg and age was 15 months. The roughage:concentrate ratio of CONF was 60:40. The animals were slaughtered at similar weights of 388.3, 386,7, and 375.8 for CONF, PTEM, and PTRO, respectively. The PTRO animals showed higher hot carcass dressing (HCD) percentage relative to 100kg of empty body weight (HCDEBW) in comparison to PTEM (64.6 versus 62.6 percent), and CONF animals showed intermediary value for HCDEBW (63.7 percent). The absolute weights of liver, 5.22, 4.43, and 3.87kg; total weights of all internal organs, 12.81, 11.37, and 10.83kg; rumen-reticulum, 7.62, 6.54, and 6.06kg; heart fat, 1.26, 0.65, and 0.30kg; and intestines, 9.97, 7.13, and 7.49kg, were higher (P<0.05) in PTEM animals than in CONF and PTRO animals, respectively. The same differences were observed concerning relative weights of the same organs. PTRO and CONF animals showed higher (P<0.05) gastrointestinal content than PTEM animals, 60.27, 55.32, and 41.21kg, respectively. Feedlot finished animals exhibited higher absolute weight of omasum, 5.17kg, than PTEM animals, 3.70kg, and PTRO animals presented intermediary value, 4,77kg. The same order was observed concerning relative weigh of the omasum, 1.61, 1.12, and 1.54 percent.

Adrenomedullary function in patients with nonclassic congenital adrenal hyperplasia.

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is classified into three types based on disease severity: classic salt-wasting, classic simple virilizing, and nonclassic. Adrenomedullary dysplasia and epinephrine deficiency have been described in classic CAH, resulting in glucose dysregulation. Our objective was to investigate adrenomedullary function in nonclassic CAH and to evaluate adrenomedullary function according to disease severity. Adrenomedullary function was evaluated in response to a standardized cycle ergonometer test in 23 CAH patients (14 females, age 9-38 years; 6 salt-wasting, 7 simple virilizing, 5 nonclassic receiving glucocorticoid treatment, 5 nonclassic not receiving glucocorticoid), and 14 controls (7 females, age 12-38 years). Epinephrine, glucose, and cortisol were measured at baseline and peak exercise. CAH patients and controls were similar in age and anthropometric measures. Patients with nonclassic CAH who were not receiving glucocorticoid and controls experienced the expected stress-induced rise in epinephrine, glucose, and cortisol. Compared to controls, patients with all types of CAH receiving glucocorticoid had impaired exercise-induced changes in epinephrine (salt-wasting: p=0.01;simple virilizing: p=0.01; nonclassic: p=0.03), and cortisol (salt-wasting: p=0.004; simple virilizing: p=0.006; nonclassic: p=0.03). Salt-wasting patients displayed the most significant impairment, including impairment in glucose response relative to controls (p=0.03). Hydrocortisone dose was negatively correlated with epinephrine response (r=-0.58; p=0.007) and glucose response (r=-0.60; p=0.002). The present study demonstrates that untreated patients with nonclassic CAH have normal adrenomedullary function. The degree of epinephrine deficiency in patients with CAH is associated with the severity of adrenocortical dysfunction, as well as glucocorticoid therapy.

[Persistent cough and bronchiectasis]. / Persistierender Husten und Bronchiektasen.

A 68 yr. old lady suffered from chronic cough. Bronchiectasis was diagnosed and treated with physiotherapy. Coughing persisted over years, although an asthma disease was controlled by inhalation, a carcinoid tumor was surgically removed, and a coronary artery disease was treated by revasculating surgery. Antibiotics and systemic corticosteroids did not relieve symptoms either. After all, diagnosis and treatment of obstructive sleep apnea led to symptom free life. We assume micro-aspiration during periods of apnea being the cause of the coughing.

Pseudo-meigs syndrome: uterine leiomyoma with bladder attachment associated with ascites and hydrothorax - a rare case of a rare syndrome.

INTRODUCTION: Pseudo-Meigs syndrome is a rare syndrome with pelvic tumors (not ovarian fibromas), which is combined with ascites and hydrothorax. Up to now 23 cases of pseudo-Meigs syndrome associated with uterine leiomyomas are described. We present a further case of a young woman with pseudo-Meigs syndrome combined with bladder attachment and elevated CA-125. CASE REPORT: A 27- year-old woman complained about increasing abdominal volume for about 2 months. Clinical results showed a normal sized uterus with a pedunculated leiomyoma, ascites, and a small pleural effusion. CA-125 levels were approximately more than 50 times higher than normal range. An explorative laparotomy revealed a leiomyoma and ascites. The myoma was attached to the posterior wall of the bladder; the rest of the uterus and both adnexae were normal. An organ-preserving operation was performed. Three months afterwards the patient presented normal clinical and sonographical findings and normal CA-125 serum levels. DISCUSSION: Uterine leiomyoma is only rarely associated with ascites and hydrothorax. Our case is the 24th in literature. Like other authors we could show elevated CA-125 serum levels. Cases of pseudo-Meigs syndrome with penduculated myomas and tight adhesions of neighbouring structures have been described frequently. In our case the bladder was tightly attached, and the vascularisation seemed to come from the uterus and the bladder. This atypical double supply might be in etiological context with the ascites. Pseudo- Meigs syndrome should be considered as a rare differential diagnosis for ascites and pleural effusions.

Effects of estrogen on growth plate senescence and epiphyseal fusion.

Estrogen is critical for epiphyseal fusion in both young men and women. In this study, we explored the cellular mechanisms by which estrogen causes this phenomenon. Juvenile ovariectomized female rabbits received either 70 microg/kg estradiol cypionate or vehicle i.m. once a week. Growth plates from the proximal tibia, distal tibia, and distal femur were analyzed after 2, 4, 6, or 8 weeks of treatment. In vehicle-treated animals, there was a gradual senescent decline in tibial growth rate, rate of chondrocyte proliferation, growth plate height, number of proliferative chondrocytes, number of hypertrophic chondrocytes, size of terminal hypertrophic chondrocytes, and column density. Estrogen treatment accelerated the senescent decline in all of these parameters. In senescent growth plates, epiphyseal fusion was observed to be an abrupt event in which all remaining chondrocytes were rapidly replaced by bone elements. Fusion occurred when the rate of chondrocyte proliferation approached zero. Estrogen caused this proliferative exhaustion and fusion to occur earlier. Our data suggest that (i) epiphyseal fusion is triggered when the proliferative potential of growth plate chondrocytes is exhausted; and (ii) estrogen does not induce growth plate ossification directly; instead, estrogen accelerates the programmed senescence of the growth plate, thus causing earlier proliferative exhaustion and consequently earlier fusion.

Adrenomedullary dysplasia and hypofunction in patients with classic 21-hydroxylase deficiency.

BACKGROUND: Glucocorticoids are essential for the normal development and functioning of the adrenal medulla. Whether adrenomedullary structure and function are normal in patients with congenital adrenal hyperplasia is not known. METHODS: We measured plasma and urinary catecholamines and plasma metanephrines in 38 children with congenital adrenal hyperplasia due to 21-hydroxylase deficiency (25 children with the salt-wasting form and 13 with the simple virilizing form), 39 age-matched normal subjects, and 20 patients who had undergone bilateral adrenalectomy. Adrenal specimens obtained from three other patients with 21-hydroxylase deficiency who had undergone bilateral adrenalectomy and specimens obtained at autopsy from eight other patients were examined histologically. RESULTS: Plasma epinephrine and metanephrine concentrations and urinary epinephrine excretion were 40 to 80 percent lower in the patients with congenital adrenal hyperplasia than in the normal subjects (P<0.05), and the values were lowest in the patients with the most severe deficits in cortisol production. Urinary epinephrine excretion and plasma epinephrine concentrations were at or below the limit of detection of the assay in 8 (21 percent) of the patients with congenital adrenal hyperplasia and in 19 (95 percent) of the patients who had undergone adrenalectomy. In the group of patients with congenital adrenal hyperplasia, plasma epinephrine and metanephrine concentrations and urinary epinephrine excretion were approximately 50 percent lower in those who had been hospitalized for adrenal crises than in those who had not. In three patients with congenital adrenal hyperplasia who had undergone bilateral adrenalectomy, the formation of the adrenal medulla was incomplete, and electron-microscopical studies revealed a depletion of secretory vesicles in chromaffin cells. CONCLUSIONS: Congenital adrenal hyperplasia compromises both the development and the functioning of the adrenomedullary system.

Leptin secretion in Cushing's syndrome: preservation of diurnal rhythm and absent response to corticotropin-releasing hormone.

The normal inverse relationship between leptin and cortisol is lost in chronic hypercortisolism. We studied this apparent dysregulation in patients with Cushing's syndrome to investigate 1) the effect of chronic hypercortisolemia on the circadian rhythm of leptin secretion, 2) the response of leptin after administration of CRH, and 3) the short term effect of curative surgery on leptin. The preoperative morning leptin concentration was 54.2 +/- 8.1 ng/mL, and the nighttime value was 68.6 +/- 9.8 ng/mL, reflecting a mean rise of 32.8 +/- 7.6%, similar to the nocturnal increase observed in normal subjects. By contrast, cortisol's diurnal variation (21.8 +/- 1.7 vs. 16.9 +/- 1.1 mg/dL) was blunted. In women, but not men, body mass index correlated with leptin (P = 0.001). Preoperative ACTH and cortisol (both P < 0.0001), but not leptin levels increased after CRH. Ten days after surgery, basal cortisol values were subnormal (1.1 +/- 0.6 mg/dL), but leptin levels remained unchanged and did not increase after CRH. Body mass index and insulin also remained unchanged. Insulin, but not age, urinary free cortisol, or plasma cortisol correlated with leptin (P < 0.05). In summary, patients with Cushing's syndrome have moderately elevated leptin levels that maintain an intact circadian rhythm but do not respond to acute or subacute alterations of cortisol.

Sequence, function, and phylogenetic analysis of an ascovirus DNA polymerase gene.

We have sequenced a 5.5-kb region of the DNA genome of the Spodoptera Ascovirus (SAV) containing a DNA polymerase gene. The gene codes for a 1104-amino-acid polypeptide with seven motifs characteristic of DNA polymerases and three additional motifs associated with polymerases possessing 3' to 5' exonuclease activity. The SAV DNA polymerase gene was able to functionally substitute for a baculovirus DNA polymerase gene in a transient assay that relies on origin-specific reporter plasmid DNA replication. Analysis of the predicted DNA polymerase sequence using neighbor-joining and protein parsimony algorithms indicated that this gene was only distantly related to other known viral and cellular DNA polymerases. The SAV DNA polymerase gene is the first ascovirus gene to be identified and sequenced. The molecular phylogenetic analyses of this gene supports the placement of insect ascoviruses in a separate virus family.

The anterior cruciate ligament-deficient knee with varus alignment. An analysis of gait adaptations and dynamic joint loadings.

Thirty-two patients with an ACL-deficient knee and lower limb varus alignment and 16 healthy controls were analyzed during level walking using a force-plate and optoelectronic system. The forces and moments of the lower limb and knee joint were measured and knee joint loads and ligament tensile forces were calculated using a mathematical model. The majority of patients (20 of 32) had an abnormally high adduction moment at the affected knee. The adduction moment showed a statistically significant correlation to high medial tibiofemoral compartment loads and high lateral soft tissue forces, but not to the degree of varus alignment on standing roentgenograms. Fifteen of 32 knees had abnormally high lateral soft tissue forces. We interpreted these gait findings as indicative of a medial shift in the center of maximal joint pressure and an increase in lateral soft tissue forces to achieve coronal plane stability. Further, there is the likelihood of separation of the lateral tibiofemoral joint and "condylar lift-off" during periods of the stance phase. If this occurs, all of the load-bearing forces would shift to the medial tibiofemoral joint and relatively large tensile forces would occur in the lateral soft tissue restraints. The flexion moment, as related to the quadriceps muscle force, was significantly lower than the control knees in 40% of the involved knees, and the extension moment, as related to the hamstring muscle force, was significantly higher in 50% of the involved knees. We interpret this finding as a gait adaptation tending to diminish quadriceps muscle activity and enhance hamstring muscle activity to provide dynamic anteroposterior stability of the knee joint. The fundamental assumption of this paper is that any combination of conditions leading to higher medial joint forces is associated with factors leading to more rapid degeneration of the medial compartment in patients with ACL deficiency, varus deformity, and lax lateral ligaments.

Purification and characterization of the cytokine-induced macrophage nitric oxide synthase: an FAD- and FMN-containing flavoprotein.

A soluble nitric oxide (NO) synthase activity was purified 426-fold from a mouse macrophage cell line activated with interferon gamma and bacterial lipopolysaccharide by sequential anion-exchange, affinity, and gel filtration chromatography. SDS/PAGE of the purified NO synthase gave three closely spaced silver-staining protein bands between 125 and 135 kDa. When assayed in the presence of L-arginine, NADPH, tetrahydrobiopterin, FAD, and reduced thiol, purified NO synthase had a specific activity of 1313 nmol of NO2- plus NO3- per min per mg. The apparent Km of the enzyme for L-arginine and NADPH was 2.8 and 0.3 microM, respectively. Addition of calcium ions with or without calmodulin did not increase the activity of the purified enzyme, and NO synthesis was not altered by calmodulin inhibitors. Gel filtration chromatography indicated that the induced NO synthase was catalytically competent as a dimer of approximately 250 kDa but could be dissociated into inactive monomers of approximately 130 kDa in the absence of L-arginine, FAD, and tetrahydrobiopterin. Upon heat denaturation, NO synthase released 1.1 mol of FAD and 0.55 mol of FMN per mol of 130-kDa subunit. Thus, inducible macrophage NO synthase differs in several respects from constitutive NO synthases and is one of very few eukaryotic enzymes containing both FAD and FMN.

A T cell epitope for experimental allergic neuritis is an amphipathic alpha-helical structure.

The bovine P2 protein is known to produce experimental allergic neuritis (EAN) in Lewis rats. The longest region of amphipathic alpha-helix within the bovine P2 protein was identified as residues 61-72. A synthetic peptide representing this sequence was synthesized and shown to have the ability to (1) produce EAN in Lewis rats by direct sensitization, (2) produce a lymphoproliferative response in a P2-specific T cell line, and (3) stimulate a P2 protein-specific T cell line sufficiently to transfer EAN to naive recipient Lewis rats. Residues 61-72 is the shortest sequence thus far identified that will produce EAN in the Lewis rat and supports the contention that T cell determinants tend to be amphipathic alpha-helices.

[Heart involvement in rheumatoid arthritis]. / Herzbeteiligung bei Rheumatoid-Arthritis.

It is reported on the malignant course of a case of rheumatoid arthritis, in which the participation of the heart became the cause of death. Here it is stated that we certainly enlarge our knowledge on the participation of the heart by modern cardiological diagnostics, but therapeutically are not yet able to engage decisively in the fateful course of the systemic rheumatoid basic disease. Therefore, efforts about an early cardiologic diagnosis are at present not yet of therapeutic consequences.